Provider Demographics
NPI:1073539409
Name:KEITH, LAURA N (CNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:N
Last Name:KEITH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:N
Other - Last Name:MASSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5640
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:421 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7236
Practice Address - Country:US
Practice Address - Phone:601-268-5640
Practice Address - Fax:601-261-3507
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRS14087363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3513360OtherAMERICAN ADMIN GROUP
MS00125348Medicaid
LA1582280Medicaid
MS3513360OtherAMERICAN ADMIN GROUP
LA1582280Medicaid